Disclaimer: Flare Capital Companions is an investor in Aetion, Cohere Well being, HealthVerity, Inbound Well being, Iora Well being and VivorCare. See the broader Flare presentation here.
That is half one in every of a two-part collection on innovation in most cancers care supply. Partly one, we’ll focus on the complexity of end-to-end most cancers care administration, the unmet wants and the way some rising digital well being gamers tackle these considerations. Partly two, we’ll spotlight the “subsequent wave” and rising developments of digital health-enabled most cancers care supply.
It is no secret: Most cancers is patently advanced.
Sufferers typically wrestle to understand the complexities of the U.S. well being system, and this confusion is usually amplified after a affected person receives a most cancers analysis. The Worldwide Company for Analysis on Most cancers forecasts the variety of new most cancers instances worldwide will attain greater than 29 million by 2040 in contrast with simply over 18 million in 2018. As remedy protocols advance and folks stay longer, generally conquering a number of cancers of their lifetime, the right storm of power illness will rise and problem our healthcare system in quite a lot of methods.
With this enhance within the variety of most cancers survivors, organizations have to be ready to deal with the following impacts of long-term toxicities, recurrence of most cancers, infertility points, cardiovascular side-effects and psychological aftereffects.
Whereas analysis exhibits cancer has surpassed heart disease because the primary explanation for dying in some high-income counties within the U.S., we’ve got not seen the identical development and adoption of digital platforms for most cancers within the ways in which we have seen for different power ailments comparable to diabetes, musculoskeletal illness and power kidney illness. So why is not extra innovation occurring for most cancers care supply?
We search to reply this query by understanding the important thing challenges opposing value-based most cancers care, and unbundling an important features of care supply, to establish the important thing developments that may affect innovation for most cancers care within the subsequent decade.
Whereas tailwinds from COVID-19 and healthcare consumerism have pushed record-setting quantities of fundraising for early-stage digital well being startups over the past three years, main challenges exist for most cancers care supply that makes this space a very tough house to disrupt.
One cause progressive care fashions comparable to value-based and home-based care haven’t seen faster adoption lies within the problem related to integrating, and sometimes reintegrating, companies across the care workforce. As we proceed to innovate for most cancers care supply, organizations have to be considerate in regards to the reintegration of care (e.g., level options). As well as, new options should empower the care groups to convey the best high quality instruments whereas additionally elevating affected person and supplier satisfaction — a troublesome steadiness to strike.
In talking with Aaron Gerber, CEO and cofounder of Reimagine Care, he famous the combination of correct instruments is not the one problem.
“When specialty medicine, we have to think about each complexity [to administer the drug] and margin it generates for the healthcare system. We will then take a phased method that begins with the decrease complexity, decrease margin medicine and develop over time, however solely after demonstrating success and elevated consolation with the affected person’s main oncology workforce,” he mentioned. “Performed properly, this will increase affected person and supplier expertise whereas offering the chance to ship very high-quality dwelling and digital care to sufferers.”
Level-solution fatigue for payers and suppliers, specialty drug buying and the chance of the perceived adjustments’ influence on profitability for present enterprise fashions typically stifle collaboration throughout stakeholders. Capital depth related to growing these strong options, typically tied to platform growth and the hiring prices for expert clinicians and care suppliers, stays a priority for early buyers as platforms scale. Different challenges embody the necessity to tightly combine surgical care into the answer to deal with larger acuity affected person populations. Add to that the widening disparity of look after underserved and rural populations, historically served by group suppliers, and also you rapidly end up in a area of competing incentives and lagging enterprise fashions.
Key parts of the most cancers care continuum have been highlighted under to phase an in any other case dastardly set of companies rendered throughout the affected person journey. Elements of the journey span the earliest stage of a affected person’s journey (comparable to discount in solar publicity and tobacco use), to superior care and end-of-life care planning.
Whereas the best alternative to disrupt conventional enterprise fashions stays to be seen for most cancers care, startups have more and more tried to enter completely different elements of the care continuum solely to run right into a slew of regulatory, incentive and integration hurdles imposed by incumbents within the house. As well as, the service-based features comparable to analysis, remedy, survivorship and end-of-life care require sturdy coordination round different features comparable to funds, training and household/caregiver help planning.
Innovation is starting to take form in numerous methods. Startups proceed to handle unmet wants by filling care gaps and supplementing present remedy types. Nonetheless, companies which have historically been non-revenue-generating appear to be a typical theme the place suppliers do not traditionally have the means to fund these initiatives, and payers are nonetheless too early in contracting for risk-based most cancers fashions. Whether or not startups can generate sustainable earnings within the short-term and show worth to stakeholders comparable to well being programs and payers stays an open query.
Regardless of preserving features of the biopharma and therapeutics house separate (we acknowledge there’s a a lot broader biotechnology and therapeutics marketplace for oncology, and quite a few firms are driving innovation ahead), essentially the most outstanding startup exercise for care supply has been in diagnostic companies, remedy coordination and threat enablement.
On the sooner aspect of the affected person continuum, prevention and threat discount options proceed to face a robust headwind as organizations attempt to combine preventative and screening-based companies with their acute care counterparts. Balancing the fee-for-service nature of acute care supply with value-based preventative companies will likely be tough; aligning incentives will likely be important. We anticipate survivorship companies (most notably, group and vitamin companies) will proceed to combine extra tightly upstream with features of acute care supply and recurrence prevention (e.g., screening, analysis).
On this market map, we spotlight a number of startups innovating throughout key classes. (See the broader Flare presentation here.)
Remedy: Leveraging information, care coordination and affected person help instruments to enhance choice making
Remedy is on the core of most cancers care supply, and we see varied options being constructed throughout the class. A lot of the present most cancers remedy plans encompass three core companies: surgical intervention, systemic remedy and radiation remedy. Relying on the stage and presenting most cancers, surgical intervention is usually the primal type of remedy for early-stage diagnoses, and it is typically complemented or augmented with each systemic (chemo, hormone and immunotherapy) and radiation remedy.
Startups, nevertheless, are addressing challenges round remedy pathways in numerous methods, specializing in issues comparable to navigation, coordination, remedy suggestions (for an knowledgeable client) and affected person help. We’ve additionally known as out dwelling care, given the rise of at-home remedy choices (comparable to dwelling infusion remedy and lab assessments), though we acknowledge many features of dwelling care in oncology fall beneath different classes comparable to screening and analysis.
The trade has additionally seen a drastic enhance within the availability of knowledge (e.g., claims, EMR, diagnostics, imaging) over the past twenty years to raised handle most cancers sufferers. Along with Flatiron Well being, there have been varied information platforms, marketplaces (HealthVerity, Graphite Health) and analytics-ready information enablers (Mendel, Aetion) rising to make information extra accessible to researchers and clinicians. Nonetheless, many challenges nonetheless exist for clinicians managing their sufferers via an evidence-based method.
“Well being programs in the present day are sometimes not set as much as make choices based mostly on real-world information. Medical trial information and different printed information is available, however organizations are starting to make the shift from the established order of printed proof (expertise-driven) to real-world proof (data-driven method) in medical apply,” mentioned Matt Bettonville, who leads Oncology Enterprise Investing at Emerson Collective.
Instruments that use real-world proof (RWE) to assist suppliers reply questions and supply clinical-decision help in a well timed method, each standalone firms (e.g, Atropos Health) or these internally developed by well being programs and educational medical facilities, are anticipated to emerge within the coming years to drive extra personalised remedy protocols.
The primary space we unbundle throughout the remedy class is navigation.
Navigation
As know-how continues to embed itself throughout the most cancers care continuum, extra alternatives have arisen for know-how to bridge the hole between present remedy regimes and in the end present extra holistic and personalised ranges of most cancers care. Even when core remedies aren’t basically altering (e.g., surgical intervention), sufferers and physicians can fine-tune features of care to the affected person utilizing information and automation to help the administration of signs, unwanted side effects, weight loss plan monitoring, appointments, affected person funds and total coordination of in any other case disparate features of care.
Navigation companies are in some ways the bedrock for sufferers navigating the complexities of care, and these companies play a important function to handle affected person’s largely unmet wants. Gamers comparable to Jasper Health provide digital care administration instruments and a library of assets to help sufferers with every part from dealing with unwanted side effects to monetary planning.
Care Coordination
Care coordination is a sizeable sub-category inside remedy that features choice help instruments to help physicians with managing affected person wants and, in principle, scale back administrative burden. One instance, Preveta, is a care coordination platform that takes illness protocols and interprets them into personalised care navigation workflows. Via automated dashboards and refined information seize, programs purpose to allow the clinician to seize extra affected person information between visits. In flip, the software program will help assess the information and get it again into the arms of the docs rapidly to enhance remedy.
One other aspect of care coordination consists of digital symptom administration, which sits on the intersection of distant monitoring instruments for patient-reported outcomes (e.g., Vinehealth, Reprosent) and proactive administration of signs via companion apps. As these startups scale, it turns into more and more vital to show improved affected person outcomes and ROI for patrons (payers, suppliers) adopting the software program. Participating payers early additionally turns into an vital issue for organizations searching for to allow threat and handle bundled companies.
Alternatively, the route of gathering and aggregating affected person information via digital affected person help instruments can grow to be a sexy alternative for pharmaceutical firms that search to faucet into distinctive affected person datapoints (comparable to social determinants of well being), which will help inform drug adoption and adherence, medical trial enablement and a number of features of drug growth.
Remedy Suggestions and Affected person Assist
As affected person information turns into extra commoditized, and clinicians are inundated with the sheer quantity of knowledge and analysis publications that aren’t humanly potential to course of, medical choice help (CDS) instruments and next-generation analytics firms that may present the “so-what” will play a central function in remedy advice and affected person administration.
Whereas Merative (previously IBM Watson Well being) and different CDS distributors primarily depend on publicly accessible tips and analysis publications, a brand new class of digital well being startups augments present tips with real-world information (RWD) and real-world proof (RWE) to supply a extra data-driven approach of treating most cancers sufferers.
“You want RWE and analytics and choice help that oncologists can get behind,” mentioned Dan McCarthy, CEO of New Century Well being and president of Evolent Well being.
Gamers comparable to Atropos Well being present options that assist physicians reply beforehand unanswered medical questions utilizing real-world medical and administrative information in a well timed method. Digital well being firms comparable to Outcomes4Me and Ciitizen emerge and attempt to help most cancers sufferers of their journey to discovering the appropriate remedy choices, and acceptable medical trials, via training and affected person help.
Traces proceed to blur as supplier organizations search to create touchpoints earlier and earlier in a affected person’s journey by establishing digital entrance doorways, and alternatively, pharmaceutical firms search to achieve entry to extra longitudinal information to help decision-making.
Dwelling-Primarily based Most cancers Care
The shift to home-based look after most cancers has been in growth for over a decade, however the current adjustments within the regulatory atmosphere have enabled sure types of remedy to be administered within the consolation of a affected person’s dwelling. Key adjustments, spawned partially by COVID-19, embody the elevated adoption and wish for care administered within the dwelling, and rising pressures on the system resulting from rising prices in key areas of spend (together with musculoskeletal, most cancers and renal).
Gamers like Reimagine Care and Karkonos are tackling dwelling infusions, lab attracts and digital visits with the objective of creating care extra reasonably priced and extra accessible. Whereas others comparable to Inbound Health and Medically Home are enabling well being programs to manage hospital-at-home for medium- and high-acuity sufferers, though the prime focus could not at all times be completely on most cancers sufferers.
Questions stay across the stage of involvement that well being programs and payers may have within the growth of dwelling well being normally. Whereas it’s nonetheless unclear precisely how and the place well being programs and AMCs will combine into the broader ecosystem, startups are starting to show (and justify) a key understanding of value when growing these home-based capabilities for most cancers.
As startups proceed to make progress in sure areas of the remedy pathway, we anticipate to see an increasing number of well being programs and payers searching for partnerships with exterior organizations as they develop their hospital-at-home and home-based companies.
Enablement and Danger-Bearing Entities: An effort to basically shift the enterprise mannequin of most cancers care to worth
Previously, oncologists have been fairly nervous about taking dangers, even professionally, resulting from nervousness round specialty drug prices. For many medical teams, the know-how wants are additionally too daunting as too many level options are sometimes wanted to correctly handle populations. Payers are additionally nonetheless within the state of transitioning, as disagreement across the stage of inclusion for specialty drug prices typically leads to a rate-limiting step for contracting.
Whereas challenges persist, current developments have enabled an increasing number of oncology teams to start transferring towards threat. As Shawn Morris, CEO of Privia Well being, mentioned, “When requested in regards to the risk by buyers and analysts, there are a number of specialties which might be excessive quantity and might underwrite the chance from an actuarial standpoint in Medicare —orthopedics, GI, urology, ophthalmology and oncology. The success of transferring into value-based preparations and threat is predicated on correct alignment with physicians and payers and having the required instruments, expertise and know-how (information) to handle threat.”
Alternatives are increasing for startups and oncology teams to start out with skilled capitation and in the end transfer upstream. These preparations are largely seen within the Medicare Benefit house, and as organizations proceed to show improved outcomes, industrial alternatives could quickly be on the horizon.
“Success in bearing threat is feasible should you design the appropriate methodology,” Robin Shah, CEO and cofounder of Thyme Care, mentioned. “This requires a deep understanding of the affected person past their medical components, and to construct that understanding it’s essential develop trusted relationships with members. With out these relationships in place, you received’t be capable of affect habits change.”
Totally different Approaches
We see innovation in threat enablement taking many types. Whether or not it’s firms comparable to Transcarent (e.g., lately introduced Transcarent Oncology Care) searching for to overtake the employer self-insured enterprise or firms taking a data-driven method to bettering broader affected person care pathways, specializing in features comparable to tumor boards, many enablement platforms are rising that drive collaboration throughout sufferers, suppliers and payers. Different gamers, comparable to Azra AI, are utilizing synthetic intelligence to interpret information in real-time to tell analysis via care administration. Thyme Care gives a nursing-led platform that’s geared up with information and analytics to proactively help most cancers sufferers’ choice making and coordination all through the method. Cohere Health appears to align medical and monetary choices holistically throughout an oncology affected person’s care journey, enabling higher collaboration and decision-making in the direction of high-value care.
If arrange appropriately, enablement platforms have the potential to supply a brand new solution to navigate members to high-quality, low-cost care, even when meaning transferring them to the very best and least costly facility in a patient-friendly approach. Current enterprise fashions have an vital cost-focused distinction that’s basically completely different in some ways in contrast with the standard, revenue-focused actions launched by giant most cancers facilities within the early 2010s (e.g., CTCA collaborates to provide free air transportation for cancer patients) that had been typically established to develop an present supplier’s footprint.
In abstract, a basic shift from historic most cancers care enterprise fashions should happen so digital well being innovation could be adopted extra rapidly. With the emergence of re-bundling applied sciences and tech-enabled companies, we anticipate the progress of risk-bearing and risk-enablement platforms to be a key side for accelerating the evolution of the most cancers enterprise mannequin.
Screening and Prognosis: Tech developments and home-enabled companies producing distinctive entry factors
Early most cancers screening and analysis can typically be the distinction between life and dying for most cancers sufferers. In line with the American Most cancers Society, the 5-year relative survival rate between two colon most cancers sufferers, one on the “localized” SEER stage (91%) and one on the “distant” SEER stage (14%), is staggering. The significance of early screening and detection of most cancers is well-established and well-known to clinicians and sufferers alike.
Over the previous twenty years, exceptional enhancements in applied sciences have allowed physicians to search out most cancers at an early stage, lengthy earlier than signs seem. From higher imaging procedures to numerous breakthrough diagnostic assessments (e.g., liquid biopsy, single-cell genomic testing, multi-OMICs), the flexibility to display and diagnose cancers has taken an enormous leap ahead.
Diagnostics
Vital enhancements in sequencing know-how and value led to the rise of firms like GRAIL, which pitches a multi-cancer early detection take a look at that may display over 50 sorts of most cancers via a single blood draw for roughly $1,000. Along with bettering novel screening and diagnostic assessments, private and non-private sectors have additionally executed their fair proportion of elevating most cancers screening consciousness and bettering entry. From varied most cancers screening campaigns from the personal sector and non-profits to CMS making a number of most cancers screening (e.g., breast most cancers, colorectal most cancers) a part of the Medicare Half C Star Scores measurement, screening and detection play a entrance and middle function on this evolution of most cancers care.
Whereas vital technological and coverage enhancements have been made, many unmet wants nonetheless exist. Boundaries embody transportation to diagnostic websites, lengthy wait instances for specialists and entry to genetic counselors. Digital well being innovators can play a vital function in addressing these unmet wants. From a affected person entry to screening standpoint, we’ve got seen non-invasive, home-based diagnostic assessments, comparable to Cologuard, which might be getting used and promoted by payers over the previous decade (e.g., Humana to cover Cologuard for colorectal cancer screening).
Modern digital well being and home-based diagnostics firms (e.g., EverlyWell) have emerged over the previous decade to enhance entry to diagnostic assessments that may be executed at point-of-care or with samples collected at dwelling. It’s not inconceivable that platforms like EverlyWell will transfer past well being and wellness assessments and use their person base to enhance most cancers screening and detection. Different rising gamers that may dramatically scale back entry limitations embody dwelling phlebotomy firms (e.g., GetLabs, Sprinter Health) that might make the blood draw extra accessible. They’ll additionally help in ongoing affected person administration for these sufferers who’re in the end identified with most cancers and may very well be enrolled in home-based most cancers administration and medical trials.
Schooling
Educating sufferers on the influence of medical remedy and way of life change stays a largely unmet want, no matter affected person acuity or circumstance. Most cancers facilities have taken a proactive step over the past twenty years to supply training instruments and companies to equip the sufferers with extra info (together with the rise of tech-enabled directories e.g., Mayo Clinic’s online resources and library), however outcomes can typically be described as “info overload,” inflicting sufferers to really feel overwhelmed.
Systematic reviews for superior most cancers sufferers and casual caregivers (e.g., partner, relations) have three widespread areas of unmet want: psychological, bodily and healthcare companies info.
A number of the largest academic gaps for sufferers lie in the advantages and unwanted side effects of remedy in addition to way of life adjustments, each after the preliminary analysis and when transitioning from lively remedy to survivorship. Schooling and care coordination startups are beginning to emerge that empower their sufferers with instruments comparable to automated aspect impact help (e.g., Ankr) that may help in ongoing, asynchronous affected person administration to supply vital power administration and inhabitants well being information.
Survivorship: An emergence of digital-hybrid communities and vitamin help to assist with a affected person’s altering way of life
Sufferers will want extra individualized help as remedy and affected person administration develop into extra focused and personalised. In in the present day’s social media-connected world, most cancers sufferers search to narrate to sufferers like them. First-generation, patient-focused social networking websites like PatientsLikeMe emerged within the 2000s, whereas new affected person communities comparable to Inspire and This is Living With Cancer have emerged to supply group help and steerage on remedy choices in newer years.
Along with peer help networks, expert-guided digital clinics, comparable to VivorCare, have emerged to supply personalized help and tailor-made packages that assist most cancers survivors handle their care exterior the hospital setting, beginning with packages designed for psychological well being. Vitamin-as-medicine continues to take off, and whereas many startups are specializing in gastrointestinal care (in lots of instances, beginning with IBD and IBS sufferers), startups are rising (Savor Nutrition, Season Health) which might be properly positioned to fill the hole for oncology sufferers with food-as-medicine, much like how these gamers are managing sufferers with power ailments comparable to diabetes.
In regards to the Authors: Ian Chiang is a associate at Flare Capital Partners, a healthcare know-how and services-focused enterprise capital agency. Previous to becoming a member of Flare, he was the SVP of product and innovation and a founding member of CareAllies, Cigna’s household of multi-payer supplier companies, inhabitants well being administration, value-based care enablement and home-based care companies. Beforehand, he was a digital well being entrepreneur and a former administration advisor at McKinsey & Firm.
Jonathon George is an MBA candidate at Kellogg College of Administration and a Flare Capital Scholar. Whereas at Kellogg, he interned on the Mayo Clinic of their Oncology Division and at OCA Ventures as an investor. Beforehand, he was a administration advisor at Chartis centered on well being programs and companies.
A particular due to Aaron Gerber, Dan McCarthy, Matt Bettonville, Ryan Langdale, Robin Shah, Shawn Morris and numerous others for offering their time and insights via a number of interviews. The workforce at Flare interviewed 20+ executives, founders, buyers, sufferers and leaders from throughout the nation on subjects associated to oncology, innovation and tech-enabled companies for most cancers care supply. This text wouldn’t be potential with out their help.
